Root Cause Analysis Blog

Ken Scott – A career at MSHA preceded Ken’s work teaching root cause analysis for System Improvements, Inc..

Recently Ken replied to the weblog article on what it took for the United States to change its mining safety practices and what it might take for China’s mining industry to change. There was so much history in one response that I wanted to share it with you (pictures were put in for the article):

It was interesting that you looked at this one explosion in Pa. You could have looked at hundreds of mine disasters over the last 100 years which resulted in thousands of miner deaths as examples of mine safety. The old saying, “mine legislation was written in blood of miners”. History shows that only after major mine disasters did our government act and institute mine legislation to improve mine safety.

The period from 1900 – 1910 was one of the bloodiest times in our mining history. Thousands were killed and injured as the nation’s mines expanded.

In 1907 the largest mine explosion in our history happened at the Monongah Mine, Monongah, WV. It killed around 362 men and boys (could not determine the exact number of deaths because no method existed for accounting for boys helping their fathers in the mines) and left over 300 widows. They could account for the number of mules because the number of mules was on their inventory. That explosion, and the many others during the decade, led to the formation of the US Bureau of Mines in 1910.

The Bureau of Mines was mainly a research and advisory agency with little authority. Advances were made in mine safety over the next 50 years, but they were slow and many accidents and disaster continued to occur.


Plus, during that time, we had the intervention and influence of mining unions that pressed for better health and safety in the mines. I’m sure their (union) involvement helped with some of the progress. Often, the single deaths that occurred almost daily in mining were not even news outside the small mining towns.

After other mine explosions, inundations, and mine roof failures, state and federal legislation was slowly changed and improved, but it always seemed to take a major disaster. Several bad mine disasters happened in the 50’s and 60’s as mechanization took place in the mines which led to the Coal Mine Act and formation of Mine Safety and Health Admin (MSHA). This legislation was the result of another disaster in WV.

In 1968 a coal mine explosion in Farmington, WV that killed 78 miners (many never recovered) led to the 1969 coal mine health and safety Act. It was changed again after another mine explosion in 1976 to include the M/NM industry.

Even today, changes in the present law seems to only take place after a major mine accident. Just this year, changes in mine seals, miner rescue chambers and mine rescue procedures, were enacted due to the mine explosion at the Sago mine in WV. As you can see, the government only gets involved due to public pressure and opinion and not always when the need is identified.

As for China, I’m not sure where to start. First of all, I’ve never make a trip to the country and only talked to some mining individuals that have toured there mines. I have had the opportunity to teach and work with delegations from China in the past when I was with MSHA. Generally, I would say that a major change or shift has to take place in their culture and attitude towards worker safety before advancements will take place. I know for a fact, China has the technology and the engineering needed to mine coal and other resources as well as we do in the States. We have had hundreds of delegations and government groups from China visit and tour out mines and we have sent many government groups and mining company individuals to share technology and information with China.

China has the engineers, equipment and know-how to do a better job. What they don’t seem to have is the same conviction to provide for miner safety and health as we have. I think China is going through the changes in human rights that we went through in the early 1900’s. The government attitude towards miner safety and human life will need to change. But as we know when it comes to human rights, China lags behind the world and what will have to change is beyond this email.

To give you one example of the attitude of mine officials regarding human care that I remember from my MSHA days was talking to one of our representatives that we sent to China. When he went into one of the underground mines in China, he noticed a miner sleeping (at least that what he thought at first) against the mine wall at the bottom of the mine shaft when he got off the elevator. He didn’t pay much attention at first and only until his trip out that evening, did it sink home. That afternoon on his way out, he noticed the same miner lying by the wall and asked what’s with the miner. He was told that the miner had died during the start of the shift. They would bring him out at the end of the shift when the turnover took place. They didn’t say that the death was a result of an accident, or give any detail, but one could only guess. It didn’t seem that urgent of a matter to bring the miner out.
Where do you start with such a culture? I’m sure improvements are taking place in China, but compared to here, they have a long was to go. I turned down a trip with a delegation to China for this very reason when I worked with the agency.

When I get back, I’ll will send you some info on mine disasters and deaths that have occurred in this country. When you look at how slow change came to this country, and the fact we have farther to go, maybe what happening in China doesn’t seem as hard to understand.

If you ever want to read a real life experience of a mine disaster (mine fire) get the book titled “Trapped, The 1909 Cherry Mine Disaster” by Karen Tintori. It makes for interesting reading on the airplanes.

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